Medical Release Form

indicates a required answer

1. *	Student's Name:

2. *	Grade:

3. *	Birthday (mm/dd/yy):

4. *	Sport(s):

In the event of an emergency occurring involving my son/daughter while at a Cornerstone Family School sponsored activity, I grant permission to the coaches to take whatever action necessary to ensure my son/daughter receives proper medial attention.

5. *	Home Phone:

6. *	Business Phone:

7.	Cell Phone:

8. *	Mailing Address:

Person to be notified, other than parent or guardian, in an emergency:

9. *	Name:

10. *	Phone Number:

11. *	Family Doctor:

12. *	Phone Number:

13. *	Insurance Company:

14. *	Policy #:

15.	Please list any medical conditions that we need to be aware of:

16.	Please list any medications that your child is currently taking and any known allergies:

17. *	Parent Signature:

18. *	Date:

By entering your name, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form.

I certify that my child, named above, is physically capable and able to fulfill requirements needed to participate in the above named sport. By signing this form, I release all obligations for the medical treatment of my son/daughter in the event of illness or injury during any sport related activity when either parent cannot be reached. If there is any physical or medical reason why he/she should not participate fully, Cornerstone Family School requires a doctor's release. Furthermore, Cornerstone Family School is not liable for any injury incurred during the sport season.